Provider Demographics
NPI:1750489779
Name:LAKE-GEAUGA RECOVERY CENTERS, INC.
Entity Type:Organization
Organization Name:LAKE-GEAUGA RECOVERY CENTERS, INC.
Other - Org Name:LAKE GEAUGA CENTER ON ALCOHOLISM AND DRUG ABUSE INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BLASKO
Authorized Official - Suffix:
Authorized Official - Credentials:LICDC
Authorized Official - Phone:440-205-2674
Mailing Address - Street 1:9083 MENTOR AVENUE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6348
Mailing Address - Country:US
Mailing Address - Phone:440-205-2674
Mailing Address - Fax:440-255-6348
Practice Address - Street 1:9083 MENTOR AVENUE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6348
Practice Address - Country:US
Practice Address - Phone:440-205-2674
Practice Address - Fax:440-255-6348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1316Medicaid